CONSIGNOR OR SHIPPER (NAME & ADDRESS)

CONSIGNEE (NAME & ADDRESS)

INTERLINE CARRIER

.ON .FER S'RONGISNOCE TAD. ON T'CCA S'RONGISNOC

NAME OF CARRIER

GST # 135863975 RT

PIECES AND TYPE OF PKGS. SHIPPING NAME / DESCRIPTION CLASSUN # PG WEIGHT LBKG

SHIPPER TRUCK #

TOTAL

NO. OF

PKGS.

ACTUAL WEIGHT

MARK WITH “X” TO DESIGNATE DANGEROUS GOODS AS DEFINED IN THE TRANSPORTATION OF DANGEROUS GOODS ACT AND REGULATIONS.

24 HR. PHONE NUMBER REQUIRED ON ALL DANGEROUS GOODS SHIPMENT.

PLACARDS REQUIRED

YES NO TYPE:

ERAP PLAN

QUOTE #

ADDITIONAL CHARGES APPLY TO /

LOADING CONFIRMATION

Employee #

STRIPPING CONFIRMATION

# of Pieces

CARRIER - DRIVER

DATE

TOTAL NO. OF PKGS.

TRAILER #

ERAP PHONE #

HEAT SHIPMENT MUST BE LABELED “HEAT”

$DECLARED VALUATION

AMOUNT $

C.O.D. SHIPMENTS

FREIGHT CHARGES

COLLECT PREPAID

THIRD PARTY**

**THIRD PARTY (NAME, ADDRESS & PHONE NO.)

C.O.D. FEECOLLECT

C O.D. FEEPREPAID

PH.

D.G.X

RESIDENTIAL/FARM/CONSTRUCTION DELIVERY

TAILGATE DELIVERY

INSIDE DELIVERY

# of Pieces

DATE

(Rev. 07/17)

TOXIC BY INHALATION (SP 23)

Shipper name (print)

Dangerous Goods Declaration

Please see our website for our complete Terms and Conditions

DECLARED VALUE (DV) FOR INS. PURPOSES. MAX. LIABILITY $2.00/LB OF THE ACTUAL WEIGHT OF THE SHIPMENT IF NO DV NOTED. INSURANCE CHARGES CALCULATED AT 3% OF DV IN EXCESS OF $2.00/LB.

THUNDER BAY (HEAD OFFICE)

DISPATCH (807) 623-3278FAX (807) 623-5606

ADMINISTRATION (807) 623-3340TOLL FREE 1-800-267-0598

340 SIMPSON ST.THUNDER BAY, ON P7C 3H7

WINNIPEG

DISPATCH (204) 927-1555FAX (204) 927-1550

TOLL FREE (877)-554-1877

60 EAGLE DRIVEWINNIPEG, MB R2R 1V5

Origin Carrier Pro No. Destination Carrier

CASH

AMOUNT

CHEQUE

$

FREIGHT CUBED

X X =

X X =

X X =

CHARGEABLE WEIGHT

TERMS: NET 30 DAYS

Freight charges will be collect unless marked prepaid. Shipper shall be responsible for charges on all freight collect and 3rd party shipments for which the carrier does not get paid.

Freight charges to be collected prior to delivery

Courtesy Freight Systems (CFS) waives all liability for freight deemed improperly packaged. Used, uncrated or inadequately packaged freight will be shipped at owner’s risk. Residential deliveries are to the door only. Carrier assumes no responsibililty for damages incurred for placement of shipment inside a residence. Personal effects must be shipped prepaid.

The shipper authorizes the carrier to transport these goods to destination by routings determined by the carrier at rates in effect on today’s date. The services performed by the carrier are subject to the conditions described on the reverse of this bill of lading.

I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, are properly classified and packaged, have dangerous goods safety marks properly affixed or displayed on them, and are in all respects in proper condition for transport according to the Transportation of Dangerous Goods Regulations.

PLACE PRO-LABEL HERE